Primary percutaneous coronary intervention in acute ST elevation myocardial infarction: Determinants of outcome
- C Michael Gibson, MS, MD
C Michael Gibson, MS, MD
- Professor of Medicine
- Harvard Medical School
- Joseph P Carrozza, MD
Joseph P Carrozza, MD
- Vice President
- Steward Cardiovascular Network
- Professor of Medicine
- Tufts University School of Medicine
- Roger J Laham, MD
Roger J Laham, MD
- Associate Professor of Medicine
- Harvard Medical School
- Duane S Pinto, MD, MPH
Duane S Pinto, MD, MPH
- Associate Professor of Medicine
- Harvard Medical School
- Section Editors
- Donald Cutlip, MD
Donald Cutlip, MD
- Section Editor — Interventional Cardiology
- Professor of Medicine
- Harvard Medical School
- Beth Israel Deaconess Medical Center
- Bernard J Gersh, MB, ChB, DPhil, FRCP, MACC
Bernard J Gersh, MB, ChB, DPhil, FRCP, MACC
- Editor-in-Chief — Cardiovascular Medicine
- Section Editor — Coronary Heart Disease; Myopericardial Disease
- Professor of Medicine
- Mayo Clinic College of Medicine
- James Hoekstra, MD
James Hoekstra, MD
- Section Editor — Adult Cardiology Emergencies
- Professor and Fredrick Glass Chair
- Wake Forest University
Patients with symptoms suggestive of an acute myocardial infarction (MI) and having electrocardiographic evidence of an acute MI manifested by ST elevations (>1 mm in two contiguous leads after nitroglycerin to rule out coronary vasospasm) that is considered to represent ischemia are candidates for reperfusion therapy with either primary percutaneous coronary intervention (PPCI) or fibrinolytic therapy. Patients with typical symptoms in the presence of a new or presumably new left bundle branch block or a true posterior MI are also considered eligible. (See "Electrocardiogram in the diagnosis of myocardial ischemia and infarction" and "Electrocardiographic diagnosis of myocardial infarction in the presence of bundle branch block or a paced rhythm".)
Coronary reperfusion with PPCI or fibrinolytic therapy improves outcomes in patients with acute ST elevation MI or an MI with a new or presumably new left bundle branch block or a true posterior MI. If performed in a timely fashion, PPCI is the reperfusion therapy of choice compared to fibrinolysis because it achieves a higher rate of TIMI 3 flow (more than 90 percent) (table 1), does not carry the risk of intracranial hemorrhage, and is associated with improved outcomes. (See 'Prognosis after primary PCI' below.)
The time to onset of reperfusion therapy is a critical determinant of outcome with both PPCI and fibrinolysis . (See "Fibrinolysis for acute ST elevation myocardial infarction: Initiation of therapy", section on 'Initiation of therapy'.)
This topic will discuss the impact of the following factors on outcomes in patients who undergo PPCI:
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- TIME FROM SYMPTOM ONSET
- Late PCI to open an occluded artery
- TIME FROM HOSPITAL ARRIVAL (DOOR-TO-BALLOON TIME)
- Outcomes in patient subgroups
- - Early versus late presentation
- - Patient risk category
- TIME FROM CONTACT WITH THE HEALTHCARE SYSTEM (SYSTEM DELAY)
- Direct transfer from the field
- Transfer from a non-PCI center
- - False positive cath lab activation
- RECOMMENDATIONS OF OTHERS
- HOSPITAL PERFORMANCE
- Nonsystem factors leading to delay
- IMPORTANCE OF LOCAL EXPERTISE
- Hospital and operator volume
- PCI without on-site cardiac surgery
- PROGNOSIS AFTER PRIMARY PCI
- TIMI flow grade
- Electrocardiographic markers
- Infarct size
- Other risk factors